﻿<%@page import="com.cchr.acms.model.Action"%>
<%@page import="com.cchr.acms.model.AbuseType"%>
<%@page import="com.cchr.acms.util.HtmlComponentUtil.SelectOption"%>
<%@page import="java.util.List"%>
<%@page import="com.cchr.acms.util.HtmlComponentUtil"%>
<%@ page language="java" contentType="text/html; charset=UTF-8"   pageEncoding="UTF-8"%>
<%@ taglib prefix="c" uri="http://java.sun.com/jsp/jstl/core"%>
<%@ taglib uri="http://java.sun.com/jsp/jstl/fmt" prefix="fmt" %>
<%@ taglib uri="http://java.sun.com/jsp/jstl/functions" prefix="fn" %>
<%@ taglib uri="http://www.acms.com/acmstag" prefix="acms" %>
<%
	String contextPath = request.getContextPath();
%>
<!DOCTYPE html>
<!--[if IE 8]>         <html class="ie8"> <![endif]-->
<!--[if IE 9]>         <html class="ie9 gt-ie8"> <![endif]-->
<!--[if gt IE 9]><!--> <html class="gt-ie8 gt-ie9 not-ie"> <!--<![endif]-->
<head>
	<meta charset="utf-8">
	<meta http-equiv="X-UA-Compatible" content="IE=edge,chrome=1">
	<title>Report Psychiatric Abuse</title>
	<meta name="viewport" content="width=device-width, initial-scale=1.0, user-scalable=no, minimum-scale=1.0, maximum-scale=1.0">

	<!-- Open Sans font from Google CDN -->
	<link href="http://fonts.googleapis.com/css?family=Open+Sans:300italic,400italic,600italic,700italic,400,600,700,300&subset=latin" rel="stylesheet" type="text/css">

	<!-- Pixel Admin's stylesheets -->
	<link href="<%=contextPath%>/assets/stylesheets/bootstrap.min.css" rel="stylesheet" type="text/css">
	<link href="<%=contextPath%>/assets/stylesheets/pixel-admin.min.css" rel="stylesheet" type="text/css">
	<link href="<%=contextPath%>/assets/stylesheets/pages.min.css" rel="stylesheet" type="text/css">
	<link href="<%=contextPath%>/assets/stylesheets/rtl.min.css" rel="stylesheet" type="text/css">
	<link href="<%=contextPath%>/assets/stylesheets/themes.min.css" rel="stylesheet" type="text/css">
	<!-- <link href="<%=contextPath%>/assets/stylesheets/select2.min.css" rel="stylesheet" type="text/css"> -->
	<link href="<%=contextPath%>/assets/stylesheets/jquery.searchableSelect.css" rel="stylesheet" type="text/css">
	<link href="<%=contextPath%>/assets/stylesheets/mobiscroll_002.css" rel="stylesheet" type="text/css">
	
	<!--[if lt IE 9]>
		<script src="<%=contextPath%>/assets/javascripts/ie.min.js"></script>
	<![endif]-->

</head>
<style type="text/css">
.page-signup-alt .panel{
	width:40%;
	margin:0 auto;
	padding:27px
}

body{
	color:black;
}

.page-signup-alt .form-header
{
	margin: 20px 0;
}

.form-group
{
	margin-bottom: 8px;
}

p a{font-size: 15px}
</style>


<!-- 1. $BODY ======================================================================================
	
	Body

	Classes:
	* 'theme-{THEME NAME}'
	* 'right-to-left'     - Sets text direction to right-to-left
-->
<body class="theme-default page-signup-alt">
	<!-- Form -->
	<form class="panel form-horizontal" id="jq-validation-form" action="<%=contextPath%>/case/create" method="POST" style="width:1000px">
		 <div id="mydiv1" style="position:relative;width:100%;height:100%;margin-bottom:40px"> 
		   <div style="position:absolute;top:0px; left:0px;width:100%;">                                                           
			<a href="http://www.cchrint.org/"><img src="<%=contextPath%>/assets/images/case/create_header.png" border="0" usemap="#Map" style="width:100%; "/></a>
			</div>
		 </div>
		 
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header"><strong>Report Psychiatric Abuse </strong></h1></label>
				</div>
			</div>
		</div>
		
		<div class="row" >
			<div class="col-sm-12">
				<div class="col-sm-3" style="color: #574d4a;">
					<a href="http://www.cchrint.org/about-us/declaration-of-human-rights/">
					<img src="<%=contextPath%>/assets/images/case/stop-the-abuse.png" class="pull-left" width="100%" height="100%" style="max-height:168px;max-width:300px;margin-right:20px;">
					</a>
					Click image to read CCHR's Mental Health Declaration of Human Rights  
				</div>
				<hr>
				<div class="col-sm-9">
					<p class="desc" style="font-size: 14px; color: black">
						<a href="http://www.cchrint.org/about-us/">Citizens Commission on Human Rights</a> is a non-profit, non-political, non-religious mental health watchdog. Its mission is to eradicate abuses committed under the guise of mental health and enact patient and consumer protections. As such, CCHR receives reports from individuals who have been abused after they sought help from psychiatrists and/or psychologists and were <a href="http://www.cchrint.org/psychiatric-disorders/">falsely diagnosed</a> and forced to undergo unwanted and harmful psychiatric treatments, such as <a href="http://www.cchrint.org/psychiatric-drugs/drug_warnings_on_violence/">psychiatric drugs which are documented to cause serious side effects</a>, involuntary commitment, or electroshock. CCHR is often able to assist people with filing complaints or work with people’s attorneys to further investigate the person’s case. 
						<br>
						If you or anyone you know has been harmed or damaged by psychiatric or mental health “treatment,” please fill out the form below with full particulars and any documentary evidence. All information received is kept in strict confidence.
					</p>
				</div>
			</div>
		</div>
		<div class="row" >
			<div class="col-sm-12">
				<div class="col-sm-6" style="color: #574d4a;">
				</div>
				<div class="col-sm-3">
					<div><a href="http://www.cchrint.org/attorneys/" class="btn btn-primary btn-rounded" style="width: 210px; height: 60px; font-size: 20px; padding-top:20px"><strong>ATTORNEYS</strong></a></div>
					&nbsp;&nbsp;<a href="http://www.cchrint.org/attorneys/">Click here for more information</a>
				</div>
				<div class="col-sm-3">
					<div><a href="http://www.cchrint.org/whistleblowers/" class="btn btn-primary btn-rounded" style="width: 210px; height: 60px; font-size: 20px; padding-top:20px"><strong>WHISTLEBLOWERS</strong></a></div>
					&nbsp;&nbsp;<a href="http://www.cchrint.org/whistleblowers/">Click here for more information</a>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<% 
						java.text.SimpleDateFormat formatter = new java.text.SimpleDateFormat("EEE, MMM d, yyyy");
						java.util.Date currentTime = new java.util.Date();//得到当前系统时间
						String str_date1 = formatter.format(currentTime); //将日期时间格式化 
					%>
					<label class="control-label"><%=str_date1%></label>
					<div class="input-group">
					</div>
				</div>
			</div>	
		</div>
		
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header"><strong>Information on the Person Abused:</strong></h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">First Name</label>
					<input type="text" class="form-control" name="abusedPerson.firstName"  placeholder="First Name">
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Middle Name</label>
					<input type="text" class="form-control" name="abusedPerson.middleName" placeholder="Middle Name">
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Last Name</label>
					<input type="text" class="form-control" name="abusedPerson.lastName"  placeholder="Last Name">
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label">Street Address</label>
					<input type="text" class="form-control" name="abusedPerson.streetAddress" placeholder="Street Address">
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">City</label>
					<input type="text" class="form-control" name="abusedPerson.city"  placeholder="City">
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">State/Province</label>
					<input type="text" class="form-control" name="abusedPerson.state"  placeholder="State/Province">
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Zip/Postal Code</label>
					<input type="text" class="form-control" name="abusedPerson.zip" placeholder="Zip/Postal Code">
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Country</label>
					<%= HtmlComponentUtil.getSelect("abusedPersonCountry", "abusedPerson.country", (List<SelectOption>)request.getAttribute("countryDatas"), "United States", "Choose Country...") %>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Phone Number</label>
					<input type="text" class="form-control" name="abusedPerson.telephone" placeholder="Phone Number">
				</div>
			</div>
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Email Address</label>
					<input type="text" class="form-control" name="abusedPerson.email" placeholder="Email Address">
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Birth Date of Abused</label>
					<div class="input-group date bs-datepicker-component" >
						<input type="text" class="form-control" id="time" name="abusedPerson.birthDay"><span class="input-group-addon" id="timeicon"><i class="fa fa-calendar"></i></span>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Or Approx. Age</label>
					<select class="form-control unRender" name="abusedPerson.age">
						<c:forEach var="item" varStatus="status" begin="1" end="100">
						  	<option value="${item }">${item }</option>
						</c:forEach>
					</select>
					
				</div>
			</div>
		</div>
	
			<label class="control-label">Approximate Date Abuse Occurred</label>
			<div class="row">
					<div class="col-sm-5">
						<div class="input-group date bs-datepicker-component">
						<input type="text" class="form-control" name="caseStart" id="starttime"><span class="input-group-addon" id="starttimeicon"><i class="fa fa-calendar"></i></span>
					</div>
								
					</div>
					<div class="col-sm-2" align="center">
						<span>To</span>
					</div>
					<div class="col-sm-5">
						<div class="input-group date bs-datepicker-component">
						<input type="text" class="form-control" name="caseEnd" id="endtime"><span class="input-group-addon" id="endtimeicon"><i class="fa fa-calendar"></i></span>
					    </div>
					</div>
			</div>
		<hr>
			
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header"><strong>Information on the Person Reporting the Abuse (if different than above):</strong></h1></label>
					<select name="differentAbusedPerson" class="unRender" id="differentAbusedPerson" onChange="showOrHide('#differentAbusedPerson', '#differentAbusedPersonForm');">
						<option value="1">Yes</option>
						<option value="0">No</option>
					</select>
				</div>
			</div>
		</div>
		<div id="differentAbusedPersonForm">
			<div class="row">
				<div class="col-sm-6">
					<div class="form-group no-margin-hr">
						<label class="control-label">Relation to the Abused Person</label>
						<%= HtmlComponentUtil.getSelect("reportedByRelation", "reportedBy.relation", (List<SelectOption>)request.getAttribute("relations"), null, "Select a relation") %>
					</div>
				</div>
				<div class="col-sm-6">
					<div class="form-group no-margin-hr">
						<label class="control-label">If other, please explain</label>
						<input type="text" disabled="disabled" id="reportedByRelationOther" class="form-control" name="reportedBy.relationOther">
					</div>
				</div>
			</div>
			<div class="row">
				<div class="col-sm-4">
					<div class="form-group no-margin-hr">
						<label class="control-label">First Name</label>
						<input type="text" class="form-control" name="reportedBy.firstName" placeholder="First Name">
					</div>
				</div>
				<div class="col-sm-4">
					<div class="form-group no-margin-hr">
						<label class="control-label">Middle Name</label>
						<input type="text" class="form-control" name="reportedBy.middleName" placeholder="Middle Name">
					</div>
				</div>
				<div class="col-sm-4">
					<div class="form-group no-margin-hr">
						<label class="control-label">Last Name</label>
						<input type="text" class="form-control" name="reportedBy.lastName" placeholder="Last Name">
					</div>
				</div>
			</div>
			<div class="row">
				<div class="col-sm-12">
					<div class="form-group no-margin-hr">
						<label class="control-label">Street Address</label>
						<input type="text" class="form-control" id="jq-validation-username" name="reportedBy.streetAddress" placeholder="Street Address">
					</div>
				</div>
			</div>
			<div class="row">
				<div class="col-sm-3">
					<div class="form-group no-margin-hr">
						<label class="control-label">City</label>
						<input type="text" class="form-control" name="reportedBy.city" placeholder="City">
					</div>
				</div>
				<div class="col-sm-3">
					<div class="form-group no-margin-hr">
						<label class="control-label">State/Province</label>
						<input type="text" class="form-control" name="reportedBy.state" placeholder="State/Province">
					</div>
				</div>
				<div class="col-sm-3">
					<div class="form-group no-margin-hr">
						<label class="control-label">Zip/Postal Code</label>
						<input type="text" class="form-control" name="reportedBy.zip" placeholder="Zip/Postal Code">
					</div>
				</div>
				<div class="col-sm-3">
					<div class="form-group no-margin-hr">
						<label class="control-label">Country</label>
						<%= HtmlComponentUtil.getSelect("reportCountry", "reportedBy.country", (List<SelectOption>)request.getAttribute("countryDatas"), "United States", "Choose country...") %>
					</div>
				</div>
			</div>
			<div class="row">
				<div class="col-sm-6">
					<div class="form-group no-margin-hr">
						<label class="control-label">Phone Number</label>
						<input type="text" class="form-control" name="reportedBy.telephone" placeholder="Phone Number">
					</div>
				</div>
				<div class="col-sm-6">
					<div class="form-group no-margin-hr">
						<label class="control-label">Email Address</label>
						<input type="text" class="form-control" name="reportedBy.email" placeholder="Email Address">
					</div>
				</div>
			</div>
		</div>
		<hr>
		
		<%
			List<AbuseType> abuseTypes = (List<AbuseType>)request.getAttribute("abuseTypes");
			if(abuseTypes != null)
			{
				for(int i=0; i<abuseTypes.size(); i++)
				{
					if(i%4 == 0)
					{
		%>
					<div class="row">
						<div class="col-sm-3">
							<div class="form-group no-margin-hr">
								<label class="control-label"><%=(i == 0 ? "Type of Abuse That Occurred<br>(Check as many as apply)" : "") %></label>					
							</div>
						</div>
		<%
					}
		%>
						<div class="col-sm-2">
							<div class="form-group no-margin-hr">
								<label class="checkbox-inline">
									<input type="checkbox" class="px" value="<%=abuseTypes.get(i).getId() %>" name="abusetypeCheckbox"> <span class="lbl"><%=abuseTypes.get(i).getName() %></span>
								</label>			
							</div>
						</div>
		<%						
					if(i%4 == 3)
					{
		%>
					</div>
		<%				
					}
				}
			}
		%>
		<hr>
		<div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Summary of Abuse That Occurred</label>				
				</div>
			</div>
			<div class="col-sm-9">
				<div class="form-group no-margin-hr">
					<textarea rows="3" class="form-control" name="summary"  placeholder="1000 characters max"></textarea>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px"><strong>Facilities Where the Abuse Occurred:</strong></h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6" style="border:1px solid #c2c2c2;padding-top:10px;border-right:0px">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">#1 - Facility Type</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("facilityInfosType1", "facilityInfos[0].type", (List<SelectOption>)request.getAttribute("facilityTypes"), null, "Select an option") %>
						</div>
					</div>
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">If other, please explain</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" id="facilityInfosTypeOther1" class="form-control" name="facilityInfos[0].typeOther">
						</div>
					</div>
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Facility Name</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[0].name" placeholder="Facility Name">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Street Address</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[0].streetAddress" placeholder="Street Address">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-1">
						<div class="form-group no-margin-hr">
							<label class="control-label">City</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[0].city" placeholder="City">
						</div>
					</div>
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">State/Province</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[0].state" placeholder="State/Province">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Zip/Postal Code</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[0].zip" placeholder="Zip/Postal Code">
						</div>
					</div>
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Country</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("facilitiesCountry1", "facilityInfos[0].country", (List<SelectOption>)request.getAttribute("countryDatas"), "United States", "Choose country...") %>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Phone Number</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[0].telephone" placeholder="Phone Number">
						</div>
					</div>
				</div>
			</div>
			<div class="col-sm-6" style="border:1px solid #c2c2c2;padding-top:10px">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">#2 - Facility Type</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("facilityInfosType2", "facilityInfos[1].type", (List<SelectOption>)request.getAttribute("facilityTypes"), null, "Select an option") %>
						</div>
					</div>
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">If other, please explain</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" id="facilityInfosTypeOther2" class="form-control" name="facilityInfos[1].typeOther">
						</div>
					</div>
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Facility Name</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[1].name" placeholder="Facility Name">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Street Address</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[1].streetAddress" placeholder="Street Address">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-1">
						<div class="form-group no-margin-hr">
							<label class="control-label">City</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[1].city" placeholder="City">
						</div>
					</div>
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">State/Province</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[1].state" placeholder="State/Province">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Zip/Postal Code</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[1].zip" placeholder="Zip/Postal Code">
						</div>
					</div>
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Country</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("facilitiesCountry2", "facilityInfos[1].country", (List<SelectOption>)request.getAttribute("countryDatas"), "United States", "Choose country...") %>
					</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Phone Number</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[1].telephone" placeholder="Phone Number">
						</div>
					</div>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px"><strong>Doctors Who Were Involved With the Abuse:</strong></h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6" style="border:1px solid #c2c2c2;padding-top:10px;border-right:0px">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">#1 - Doctor First Name</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[0].name" placeholder="Doctor First Name">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">#1 - Doctor Last Name</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[0].lastName" placeholder="Doctor Last Name">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">#1 - Doctor Type</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("doctorInfos1", "doctorInfos[0].docType", (List<SelectOption>)request.getAttribute("docTypes"), null, "Choose a doctor type...") %>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Street Address</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[0].streetAddress" placeholder="Street Address">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-1">
						<div class="form-group no-margin-hr">
							<label class="control-label">City</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[0].city" placeholder="City">
						</div>
					</div>
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">State/Province</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[0].state" placeholder="State/Province">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Zip/Postal Code</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[0].zip" placeholder="Zip/Postal Code">
						</div>
					</div>
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Country</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("doctorCountry1", "doctorInfos[0].country", (List<SelectOption>)request.getAttribute("countryDatas"), "United States", "Choose country...") %>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Phone Number</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[0].telephone" placeholder="Phone Number">
						</div>
					</div>
				</div>
			</div>
			<div class="col-sm-6"  style="border:1px solid #c2c2c2;padding-top:10px;">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">#2 - Doctor First Name</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[1].name" placeholder="Doctor First Name">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">#2 - Doctor Last Name</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[1].lastName" placeholder="Doctor Last Name">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">#2 - Doctor Type</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("doctorInfos2", "doctorInfos[1].docType", (List<SelectOption>)request.getAttribute("docTypes"), null, "Choose a doctor type...") %>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Street Address</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[1].streetAddress" placeholder="Street Address">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-1">
						<div class="form-group no-margin-hr">
							<label class="control-label">City</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[1].city" placeholder="City">
						</div>
					</div>
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">State/Province</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[1].state" placeholder="State/Province">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Zip/Postal Code</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[1].zip" placeholder="Zip/Postal Code">
						</div>
					</div>
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Country</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("doctorCountry2", "doctorInfos[1].country", (List<SelectOption>)request.getAttribute("countryDatas"), "United States", "Choose country...") %>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Phone Number</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[1].telephone" placeholder="Phone Number">
						</div>
					</div>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px"><strong>Were Psychiatric Drugs Prescribed?</strong></h1></label>
					<select name="drugsPrescribed" class="unRender" id="PrescribedDrugs" onChange="showOrHide('#PrescribedDrugs', '#PrescribedDrugsForm');">
						<option value="0">No</option>
						<option value="1">Yes</option>
					</select>
				</div>
			</div>
		</div>
		<div id="PrescribedDrugsForm"  style="display: none;">
			<!-- 
			<div class="row drug-form">
				<div class="col-sm-12">
					<div class="form-group no-margin-hr">
						<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px"><strong>What Psychiatric Drugs Were Prescribed?</strong></h1></label>
					</div>
				</div>
			</div>
			<div class="row drug-form">
				<div class="col-sm-4">
					<div class="form-group no-margin-hr">
						<label class="control-label">How long were the drugs taken for?</label>				
					</div>
				</div>
				<div class="col-sm-4">
					<div class="form-group no-margin-hr">
						<input type="text" class="form-control" name="drugsTakeTime" >
					</div>
				</div>
			</div>
			<div class="row drug-form">
				<div class="col-sm-4">
					<div class="form-group no-margin-hr">
						<label class="control-label">What dosage was prescribed?</label>				
					</div>
				</div>
				<div class="col-sm-4">
					<div class="form-group no-margin-hr">
						<input type="text" class="form-control" name="drugsDosage" >
					</div>
				</div>
			</div>
			 -->
			<div class="row drug-form">
				<div class="col-sm-1">
					<div class="form-group no-margin-hr">
						<label class="control-label">#1</label>		
							
					</div>
				</div>
				<div class="col-sm-3">
					<div class="form-group no-margin-hr">
						<%= HtmlComponentUtil.getSelect("id_1", "drugIds", (List<SelectOption>)request.getAttribute("datas"), null, "Select an option") %>
					</div>
				</div>
				<div class="col-sm-1">
					<div class="form-group no-margin-hr">
						<label class="control-label">#2</label>				
					</div>
				</div>
				<div class="col-sm-3">
					<div class="form-group no-margin-hr">
						<%= HtmlComponentUtil.getSelect("id_2", "drugIds", (List<SelectOption>)request.getAttribute("datas"), null, "Select an option") %>
					</div>
				</div>
				<div class="col-sm-1">
					<div class="form-group no-margin-hr">
						<label class="control-label">#3</label>				
					</div>
				</div>
				<div class="col-sm-3">
					<div class="form-group no-margin-hr">
						<%= HtmlComponentUtil.getSelect("id_3", "drugIds", (List<SelectOption>)request.getAttribute("datas"), null, "Select an option") %>
					</div>
				</div>
			</div>
			<div class="row drug-form">
				<div class="col-sm-1">
					<div class="form-group no-margin-hr">
						<label class="control-label">#4</label>				
					</div>
				</div>
				<div class="col-sm-3">
					<div class="form-group no-margin-hr" >
						<%= HtmlComponentUtil.getSelect("id_4", "drugIds", (List<SelectOption>)request.getAttribute("datas"), null, "Select an option") %>
					</div>
				</div>
				<div class="col-sm-1">
					<div class="form-group no-margin-hr">
						<label class="control-label">#5</label>				
					</div>
				</div>
				<div class="col-sm-3">
					<div class="form-group no-margin-hr">
						<%= HtmlComponentUtil.getSelect("id_5", "drugIds", (List<SelectOption>)request.getAttribute("datas"), null, "Select an option") %>
					</div>
				</div>
				<div class="col-sm-1">
					<div class="form-group no-margin-hr">
						<label class="control-label">#6</label>				
					</div>
				</div>
				<div class="col-sm-3">
					<div class="form-group no-margin-hr">
						<%= HtmlComponentUtil.getSelect("id_6", "drugIds", (List<SelectOption>)request.getAttribute("datas"), null, "Select an option") %>
					</div>
				</div>
			</div>
			<div class="row drug-form">
				<div class="form-group no-margin-hr">
					<label class="col-sm-4 control-label" style="color: black">Are you/they still taking psychiatric drugs?</label>
					<div class="col-sm-1">
						<select name="stillTakeDrugs" class="unRender" style="margin-top: 10px" id="stillTakeDrugs">
							<option value="0">No</option>
							<option value="1">Yes</option>
						</select>
					</div>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px"><strong>Are You Working With an Attorney?</strong></h1></label>
					<select class="unRender" name="attorney.workWithAttorney" id="attorneyWorkWithAttorney" onChange="showOrHide('#attorneyWorkWithAttorney', '#attorneyWorkWithAttorneyForm');">
						<option value="1">Yes</option>
						<option value="0"  selected = "selected">No</option>
					</select>
				</div>
			</div>
		</div>
		
		<div class="row attorney-form" id="attorneyWorkWithAttorneyForm" style="display: none;">
			<div class="form-group no-margin-hr">
				<label class="col-sm-2 control-label">Attorney Name</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" name="attorney.name" placeholder="Attorney Name">
				</div>
			</div>
			<div class="form-group no-margin-hr">
				<label class="col-sm-2 control-label">Street Address</label>
				<div class="col-sm-4">
					<input type="text" class="form-control" name="attorney.streetAddress" placeholder="Street Address">
				</div>
				<label class="col-sm-2 control-label">City</label>
				<div class="col-sm-4">
					<input type="text" class="form-control" name="attorney.city" placeholder="City">
				</div>
			</div>
			<div class="form-group no-margin-hr">
				<label class="col-sm-2 control-label">State/Province</label>
				<div class="col-sm-4">
					<input type="text" class="form-control" name="attorney.state" placeholder="State/Province">
				</div>
				<label class="col-sm-2 control-label">Zip/Postal Code</label>	
				<div class="col-sm-4">
					<input type="text" class="form-control" name="attorney.zip" placeholder="Zip/Postal Code">
				</div>
			</div>
			<div class="form-group no-margin-hr">
				<label class="col-sm-2 control-label">Country</label>
				<div class="col-sm-4">
					<%= HtmlComponentUtil.getSelect("attorneyCountry", "attorney.country", (List<SelectOption>)request.getAttribute("countryDatas"), "United States", "Choose country...") %>
				</div>
				<label class="col-sm-2 control-label">Phone Number</label>
				<div class="col-sm-4">
					<input type="text"  class="form-control" name="attorney.telephone" placeholder="Phone Number">
				</div>
			</div>
			<div class="form-group no-margin-hr">
				<label class="col-sm-2 control-label">Email Address</label>
				<div class="col-sm-4">
					<input type="text" class="form-control" name="attorney.email" placeholder="Email Address">
				</div>
				<label class="col-sm-2 control-label">Current Status of Case</label>
				<div class="col-sm-4">
					<input type="text" class="form-control" name="attorney.status" placeholder="Current Status of Case">
				</div>
			</div>
		</div>
		<div class="row" id="assistanceAttorney-form">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px"><strong>Would Like Assistance in Getting an Attorney to File Charges or Represent Your Case?</strong></h1></label>
					<input type="checkbox" value="1"  name="attorney.assistanceAttorney">
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px"><strong>What Actions Are You Interested in Taking on This Case?</strong></h1></label>
				</div>
			</div>
		</div>
		<%
			List<Action> actions = (List<Action>)request.getAttribute("actions");
			if(actions != null)
			{
				for(Action action : actions)
				{
		%>
			<div class="row">
				<div class="col-sm-12">
					<div class="form-group no-margin-hr">
						<label class="checkbox-inline">
							<input type="checkbox" class="px" value="<%=action.getId() %>" name="actionsCheckbox"> <span class="lbl" style="color: black"><%=action.getName() %></span>
						</label>			
					</div>
				</div>
			</div>
		<%
				}
			}
		%>
		
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<!-- <input type="checkbox" class="px" id="otherActionCheck" >  --><span class="lbl"><input type="text" id="otherActionInput" class="form-control" name="otherAction" placeholder="Other"></span>
					</label>			
				</div>
			</div>
		</div>
		
		<hr>
			<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px"><strong>Preferred Contact</strong></h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="input-group">
					<label class="control-label">Best time to contact you?</label>
					<input type="text" class="form-control" name="bestTimeToContact" placeholder="Best Time">
				</div>
			</div>
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Best way to contact you?</label>
					<input type="text" class="form-control" name="bestWayToContact" placeholder="Best Way">
				</div>
			</div>
		</div>
		<br>
		<div class="row">
			<div class="col-sm-3">
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-2">
					</div>
					<div class="col-sm-8">
						<input type="submit" value="Submit" class="btn btn-primary btn-lg btn-block" style="border-radius:15px; font-size: 20px">
					</div>
				</div>
			</div>
		</div>
		<br>
		<br>
	 	<div id="mydiv2" style="position:relative;width:100%;height:170px;margin-bottom:20px"> 
		   <div style="position:absolute;top:0px; left:0px;width:100%;">  		
			  <a href="http://www.cchrint.org/" style="display:block; width:100%; height:100%;"><img src="<%=contextPath%>/assets/images/case/create_footer.png" border="0" usemap="#Map2" style="width:100%;"></a>
			</div>
		</div>
		</form>



	
	<!-- / Form -->

<!-- Get jQuery from Google CDN -->
<!--[if !IE]> -->
	<script type="text/javascript"> window.jQuery || document.write('<script src="<%=contextPath%>/assets/javascripts/jquery-2.0.3.min.js">'+"<"+"/script>"); </script>
<!-- <![endif]-->
<!--[if lte IE 9]>
	<script type="text/javascript"> window.jQuery || document.write('<script src="<%=contextPath%>/assets/javascripts/jquery-1.8.3.min.js">'+"<"+"/script>"); </script>
<![endif]-->


<!-- Pixel Admin's javascripts -->
<script src="<%=contextPath%>/assets/javascripts/bootstrap.min.js"></script>
<!-- <script src="<%=contextPath%>/assets/javascripts/pixel-admin.min.js"></script> -->
<!-- <script src="<%=contextPath%>/assets/javascripts/select2.min.js"></script> -->
<script src="<%=contextPath%>/assets/javascripts/jquery-1.11.1.min.js"></script>
<script src="<%=contextPath%>/assets/javascripts/jquery.searchableSelect.js"></script>
<script src="<%=contextPath%>/assets/javascripts/mobiscroll_002.js"></script>
<script type="text/javascript">
    $(function () {

		var currYear = (new Date()).getFullYear();	
		var opt={};
		opt.date = {preset : 'date'};
		opt.datetime = {preset : 'datetime'};
		opt.time = {preset : 'time'};
		opt.default = {
			theme: 'android-ics light', //皮肤样式
	        display: 'modal', //显示方式 
	        mode: 'scroller', //日期选择模式
			dateFormat: 'mm/dd/yyyy',
			lang: 'zh',
			showNow: true,
			nowText: "Today"
		};
		opt.noToday = {
				showNow: false
		};

	  	$time = $("#time").mobiscroll($.extend(opt['date'], opt['default'], opt['noToday']));
	  	$('#timeicon').click(function(){
	  		$("#time").mobiscroll('getInst').show();
		 });
	  	$("#starttime").mobiscroll($.extend(opt['date'], opt['default']));
	  	$('#starttimeicon').click(function(){
	  		$("#starttime").mobiscroll('getInst').show();
		 });
	  	$("#endtime").mobiscroll($.extend(opt['date'], opt['default']));
	  	$('#endtimeicon').click(function(){
	  		$("#endtime").mobiscroll('getInst').show();
		 });
	  	var optDateTime = $.extend(opt['datetime'], opt['default']);
	  	var optTime = $.extend(opt['time'], opt['default']);

	    $('#abusedPersonCountry').searchableSelect();
	    $('#reportCountry').searchableSelect();
		$('#facilityInfosType1').searchableSelect();
		$('#facilitiesCountry1').searchableSelect();
		$('#facilityInfosType2').searchableSelect();
		$('#facilitiesCountry2').searchableSelect();
		$('#doctorInfos1').searchableSelect();
		$('#doctorCountry1').searchableSelect();
		$('#doctorInfos2').searchableSelect();
		$('#doctorCountry2').searchableSelect();
		$('#attorneyCountry').searchableSelect();
		for(var j=1; j<7; j++)
		{
			$('#id_' + j).searchableSelect();
		}
	});
</script>
<!-- <script type="text/javascript">
	window.PixelAdmin.start([
		function () {
			$("#signup-form_id").validate({ focusInvalid: true, errorPlacement: function () {} });

			
		}
	]);
</script>-->

<!-- Javascript -->
	<script>var init = [];</script>
	<script>

	function showOrHide(target, clazz)
	{
		if($(target).val() == '0')
		{
			$(clazz).hide();
		}
		else
		{
			$(clazz).show();
		}
		if($(target).attr('id') == 'attorneyWorkWithAttorney')
		{
			if($(target).val() == '0')
			{
				$('#assistanceAttorney-form').show();
			}
			else
			{
				$('#assistanceAttorney-form').hide();
			}
		}
	}
	
		init.push(function () {
			
			var options1 = {
					autoclose: true
				}
			$('.bs-datepicker-component').datepicker(options1);
			
			var options2 = {
				orientation: $('body').hasClass('right-to-left') ? "auto right" : 'auto auto',
				autoclose: true
						
			}
			$('#bs-datepicker-range').datepicker(options2);
			
			$("select:not(.unRender)").select2({
			    allowClear: true
			});

			$('#otherActionCheck').click(function(){
				if($('#otherActionCheck')[0].checked)
				{
					$('#otherActionInput').attr('disabled', false);
				}
				else
				{
					$('#otherActionInput').attr('disabled', true);
					$('#otherActionInput').val('');
				}
			});

			$('#reportedByRelation').change(function(){
				if($(this).val() == 'Other')
				{
					$('#reportedByRelationOther').attr('disabled', false);
				}
				else
				{
					$('#reportedByRelationOther').attr('disabled', true);
					$('#reportedByRelationOther').val('');
				}
			});

			$('#facilityInfosType1').change(function(){
				if($(this).val() == 'Other')
				{
					$('#facilityInfosTypeOther1').attr('disabled', false);
				}
				else
				{
					$('#facilityInfosTypeOther1').attr('disabled', true);
					$('#facilityInfosTypeOther1').val('');
				}
			});

			$('#facilityInfosType2').change(function(){
				if($(this).val() == 'Other')
				{
					$('#facilityInfosTypeOther2').attr('disabled', false);
				}
				else
				{
					$('#facilityInfosTypeOther2').attr('disabled', true);
					$('#facilityInfosTypeOther2').val('');
				}
			});
			
			showOrHide($('#attorneyWorkWithAttorney'), '#attorneyWorkWithAttorneyForm');
			showOrHide($('#differentAbusedPerson'), '#differentAbusedPersonForm');
			showOrHide($('#PrescribedDrugs'), '#PrescribedDrugsForm');
			showOrHide($('#userInsurance'), '#userInsuranceForm');
			
			$("#jq-validation-form").validate({
				ignore: '.ignore',
				focusInvalid: true,
				rules: {
					'abusedPerson.firstName': {
						required: true
					},
					'abusedPerson.city': {
						required: true
					},
					'abusedPerson.telephone': {
						required: true
					},
					'abusedPerson.email': {
					  required: true,
					  email: true
					},
				}
			});
			
			
		});
		//window.PixelAdmin.start(init);
	</script>
	<script type="text/javascript">		
		var oJqForm=document.getElementById('jq-validation-form');
		var clientW=document.documentElement.clientWidth;
		if(clientW<1000){
			oJqForm.style.width=clientW+"px";
		}
	</script>

</body>
</html>
